SAM URETSKY

Narcs Crack Down on Pain Relievers

Medical science is wonderful, as long as you're dealing with
something really esoteric and unpronounceable. There are great things
happening in the field of surgery, using computers and miniaturized
television cameras. Heart transplants are an everyday affair, and
there are new drugs for cancer, and even AIDS while not curable, can
be controlled for periods of years.

But the common cold is still with us, the flu doubly so this year,
and the best that can be done for male pattern baldness is to slow
down hair loss until you've reached an age where sex appeal isn't a
concern.

And there is no good treatment for pain, which is about as basic
as you can get. There are lots of treatments, and most of them work
for a little while, but there's nothing that works well for a long
time.

There are three basic types of analgesics: acetaminophen, NSAIDs,
and narcotics. Acetaminophen (Tylenol is the best known brand) works
for mild pain, and as long as you keep the dose low enough, it's
safe. It's not useful for more severe pain.

NSAIDs, non-steroidal anti-inflammatory drugs, are a large group
of compounds including aspirin, ibuprofen (Advil, Motrin), naproxene
(Aleve, Naprosyn) and lots of others. They can relieve pain fairly
well, but they also cause ulcers and bleeding. One British study
indicated that one-third of hospital admissions of patients over the
age of 65 was due to the side effects of NSAIDs. The newer drugs in
this class, Celebrex and Vioxx, were supposed to correct this
problem, but the recent withdrawal of Vioxx because of an increased
death rate throws things back to the drawing board.

Narcotics such as morphine, codeine, meperidine (Demerol) and
close relatives such as propoxyphene (Darvon) are generally effective
even against severe pain, but they have their own list of adverse
effects and, perhaps even more significantly, a host of legal
restrictions.

Narcotics are addictive, and a societal problem, and some portion
of the narcotics drugs which enter the system for legitimate medical
use do get diverted to drug abuse. Because of this, the Drug
Enforcement Administration keeps a wary eye on any physician, any
pharmacist, who prescribes or dispenses large quantities of
narcotics.

On Oct. 19 the New York Times reported on the case of a physician
who was jailed for narcotics diversion which, it was originally
stated, led to the deaths of some of his patients. "He lost his home
and his medical practice and served five months in jail before it was
discovered that the patients had died from accidents or from medical
illnesses, not from the narcotics he prescribed."

Fear of regulatory agencies has been a problem for physicians who
try to practice responsible pain management. While some patients
legitimately need high-dose narcotics, some inspectors seem to see
any M.D. with a pain practice as a legitimate target. Physicians and
pharmacists become afraid to prescribe and dispense the narcotics
needed for adequate pain control. Patients with severe pain syndromes
live in fear that they may not be able to get their medication.

The National Institutes of Health has issued guidelines calling
for more aggressive treatment of pain, but good clinical medicine
doesn't mean much compared with the risk of jail time and loss of a
medical license. Dr. Russell Portenoy, a leading pain management
specialist, has estimated that 40% of patients with severe pain are
being undertreated.

On Aug. 11, the Associated Press reported that the DEA, in
cooperation with leading pain experts, published guidelines for
treatment of pain. David Joranson, director of pain policy at the
University of Wisconsin-Madison Medical School, who helped write the
guidelines was quoted as saying "Pain medicine is not to contribute
to abuse, and law enforcement is not to interfere in patient care."
As long as physicians followed the proper steps in examination and
record keeping, they were assured that they could prescribe narcotics
without concern for regulatory interference.

On Oct. 21st, the Washington Post reported that the DEA had
withdrawn its support for the guidelines, and had taken the document
off its web site earlier in the month. The agency gave no explanation
except to say that it contained "misstatements." The physicians who
had worked with the DEA said they had been given no indication that
the agency was dissatisfied with the guidelines or intended to remove
them. The Post reported that the DEA's decision might have been
related to a request by defense attorneys to introduce the guidelines
in a pending case against a Virginia physician. After the defense had
asked to introduce the guidelines, the prosecuting attorney filed a
motion in the case asking that the guidelines be excluded as
evidence, saying that they do "not have the force and effect of
law."

There's no question that some narcotics get diverted from
legitimate use to drugs of abuse. The amount, though, is probably a
lot less than the amount of opium being shipped in from Afghanistan
now that the US is busy in Iraq. Meanwhile, Blackstone's injunction
that it is better for 10 guilty people to go free than for one
innocent person to suffer has gone out the window in the relentless
pursuit of high conviction rates -- and so has a carefully crafted
compromise that, for a short time, promised to make it safe to
practice responsible medicine.

Addendum: last summer the American Medical Association rejected a
proposal that physicians refuse to treat trial lawyers. Given the
attitude of the DEA, it seems that trial lawyers are worth saving
after all.